Two decades ago, you took a book and a thermos into A&E and waited; ten years ago, a patient complained to me that he had been seen so fast he had not been able to read his book at all! Now people prepare to sit it out, charging their smartphones and buying a coffee, as the waits in A&E increase once again.
So, what of a golden age in A&E?
The successes were built over several years of introducing processes to reduce duplication and enable staff to work more efficiently. The evidence that emerged from that era highlighted the successes but failed to identify fully why things had worked or under what circumstances.
Today’s problems tend to relate to the whole system — patients wait for ambulances, which are still queuing for drop-off at hospital, or wait in overcrowded A&E departments, first for someone free to see them and then for a bed in a ward. Crowded hospitals are amazingly inefficient because there is no flexibility; there is always something to do before you can do whatever is urgent now. And the pattern extends, as wards struggle to discharge patients who first need support to be arranged at home or (where the visit has had life-changing consequences) who need a new home for the coming years.
There are plenty of initiatives across the NHS to resolve this but the people who are rigorous in appraising new treatments seem not to have been heard when it comes to process change. Blindly adopting a successful solution from elsewhere is like giving antibiotics to the next patient because they worked for the last.
I see too many initiatives that work for days or weeks and then fail. It is usually down to ABC –attitudes, behaviour, and culture in the organisation. In my experience failure is commonly associated with solutions that are imposed on staff, forgetting that a socio-technical system like healthcare needs to combine scientific rigour with sociological insight.
So why is it that in health, even simple operations management approaches are ignored? Other service industries have detailed knowledge of demand and what capacity they need to deal with the normal workload and with surges. Other sectors would have modelled the changes before implementing them and produced the evidence for change in their specific circumstances.
Maybe we need a different book to read the next time we are in A&E.
Professor Matthew Cooke